This briefing paper, which we reprint here in edited form, was recently produced by the American Medical Association and discusses the alcohol industry's rôle in prevention programmes. It offers a guide to public health professionals and activists for understanding and responding to the alcohol industry's public awareness and education initiatives.

The alcohol industry has become a major funder and designer of prevention and education programmes. Anheuser-Busch's sponsorship of social norms marketing, a new strategy for preventing alcohol problems on American college campuses, is a recent example. The beer giant's support has triggered a healthy debate in the higher education and public health communities. Does it taint the programmes? Given the company's aggressive marketing to college students, should universities refuse the funds? Will the funding undermine efforts to restrict those marketing practices? Many recipients respond that the funding is essential to their programmes and the company has not influenced their design or implementation. Anheuser-Busch declares that it is acting as a good corporate citizen: Its marketing does not target or influence young people, and it is seeking avenues to reduce the abuse of its products, promote responsible drinking practices, and build partnerships with worthy prevention programmes. This debate is not limited to college campus communities. The industry has entered the prevention arena aggressively in local communities, school districts, and states, and at national and international levels. It has developed school curricula and parent guides, subsidized educational programmes and scholarships.

Its central thesis is that the programmes offered by the alcohol industry can only be understood in the context of the industry's marketing and political agendas. The paper is divided into five parts that provide:

• a description of the industry's structure and market, and common misconceptions regarding consumption patterns;

• a review of the industry's marketing strategies and their impact on social norms and the alcohol environment;

• an introduction to the environmental approach to prevention and its rôle in

• addressing industry marketing strategies;

• an analysis of industry awareness and education programmes and their rôle in its marketing and political agenda;

• recommendations for negotiating with and responding to industry prevention initiatives.

The Alcohol Industry and its Market: The Importance of Hazardous and Heavy Drinking

The alcohol market generates huge sales and profits. The alcohol industry pursues an enormous market in the United States: $115 billion in annual sales generate substantial profits for producers, distributors and retailers. Anheuser-Busch Co., the largest brewer, reported a net income in 2000 in excess of $1.5 billion. As with any business, the alcohol industry's primary focus is on maximizing profits. As stated in the 1997 Anheuser-Busch annual report: "Every action taken by ... management is guided by one overriding objective - enhancing shareholder value."

The alcohol production market is concentrated in a small number of large companies. A handful of large companies control the market, and their numbers have steadily shrunk during two decades of corporate mergers. Beer is by far the most concentrated market, with only two companies, Anheuser-Busch and Philip Morris (owner of Miller Brewing Company), accounting for two-thirds of all beer sales. Together with these two, eight other alcohol companies that sell beer, wine and distilled spirits, account for approximately 70 per cent of all US alcohol sales (measured in terms of pure alcohol).

Producers are the dominant power within the alcohol market. Producers, distributors, and retailers have distinct, sometimes conflicting, interests. In general, retailers face more regulation, particularly at the state level, and are more directly accountable to consumers and communities. Yet retailer and distributor practices are largely dictated by the producers' marketing programmes.

A small per centage of drinkers consume most of the alcohol sold. The heaviest five per cent of the drinkers (averaging more than four drinks per day) consume 42 per cent of the alcohol sold.

Young people who consume hazardous quantities of beer are the alcohol industry's most important customers. Hazardous drinking, defined as 5 drinks or more per day, accounts for more than half the alcohol industry's market and 76 per cent of the beer market. Hazardous drinking practices first appear during 8th grade, increase dramatically during the early college years, then decline by the time respondents are 25 and older. Thus, 16- to 25-year-olds constitute a critical part of the alcohol market, particularly for brewers.

Underage drinkers are a substantial part of the alcohol market and a key consumer group. There are varying estimates of the underage drinking market. Eigen and Noble (1994) concluded that underage drinkers account for approximately 10 per cent of the alcohol market, or almost $10 billion annually.

The Inspector General for the U.S. Department of Health and Human Services estimated in 1991 that students in 7th through 12th grades annually consume 1.1 billion cans of beer and about 35 per cent of all wine coolers sold in the United States. Most of this consumption occurs in a hazardous fashion (five or more drinks in a single session). Youth consumption is also critical to the alcohol market because it sets the stage for long-term adult drinking habits. Early onset of drinking is correlated with heavier drinking, higher injury rates, and learning deficits later in life.

Conversely, most young people and adults drink very little or not at all. Seven in ten American adults drink less than one drink on average per week, and three of these seven abstained altogether in the last year. Only about 10 per cent of the adult population consume moderate amounts (defined by the federal government as from one to two drinks per day), despite a popular belief that most Americans consume alcohol in moderation. Young people are even more likely to be light consumers or abstainers: 83 per cent of 12- to 17-year-olds reported abstaining in the past month.

Most people overestimate the levels of alcohol consumption in our society. As these data suggest, alcohol is not an important part of life for most Americans. Yet we generally concur with the alcohol industry's common assertion that "the overwhelming majority of adults drink [alcohol] responsibly." This is true only if you include abstainers and very light drinkers; moderate drinkers (those who average two drinks or less a day) make up only about one quarter of the industry's sales.

Young people in particular are likely to overestimate the alcohol consumption of their peers. Several studies have found that college students are likely to overestimate the drinking frequency of their fellow students and the drinking norms on their campuses. Misperceptions of drinking norms have the most impact on the heaviest student drinkers, who are more likely to drink more when they believe that their student peers drink heavily and the college community condones such behaviour. These findings have implications for society at large: our permissive norms regarding drinking may have their biggest impact on heavy drinkers.

Social Norms, the Alcohol Environment, and Alcohol Industry Marketing Strategies

College-based social norms prevention programmes focus precisely on these misperceptions: if we inform college students of actual drinking practices, then they will moderate their consumption. Several studies suggest that this is a promising approach, although their evaluation designs are weak and findings are inconsistent. The programmes may have only limited or no success with some student groups, particularly heavy drinkers; they need to be carefully tailored and monitored; and their long-term impact is largely unknown. Still, doesn't the alcohol industry's support of these programmes suggest a good faith effort to promote moderate drinking? To answer this question, one must examine what social norms programmes omit - the social environment that shapes and reinforces those norms. These industry-supported programmes focus on educating students to actual drinking practices. A community's social norms and expectations about drinking emerge from and reflect the community alcohol landscape or environment, including such factors as messages in the media and elsewhere regarding alcohol use; the ease of obtaining alcohol through commercial and noncommercial sources; the price of alcohol; and the rôle of alcohol in community events, workplaces, and social institutions. This landscape is shaped by alcohol policies and policy enforcement, formal and informal laws and rules regarding when, how much, and where drinking can and should take place. Social norms programmes omit these variables, leaving untouched the alcohol industry's ability to promote and sell its products with as few restrictions as possible.

The alcohol industry's marketing practices promote an alcohol environment and alcohol policies that support and normalise the very drinking patterns and practices that social norms programmes purport to prevent. Community alcohol environments (particularly those surrounding college campuses) typically encourage heavy alcohol use and downplay its potential harms to public health and safety.Ironically, the environments reflect and reinforce misconceptions about alcohol use in our society. We make alcohol use normal, convenient, and cheap in part because we believe this responds to the demands of most people. In fact, as noted above, most Americans drink very little or not at all.

Four P's of marketing (product, promotion, place and price) is a helpful typology for understanding the industry's marketing strategies. These variables are used by marketers generally to create social environments that encourage consumers to purchase their products.

Product - New alcohol products target youthful consumers and may promote abusive drinking practices. Sweet, fruity alcohol products popular with teenagers blur the line between alcohol and soft drinks. Alcopops are the latest entry in this drink category. Many of the largest alcohol producers are now aggressively marketing these lemonade-flavoured beverages that mask the taste of the five per cent alcohol they contain. Teenagers are far more likely than adults to be familiar with and consume alcopop brands. Malt liquors, which offer high alcohol content at low prices, are sold in 40-ounce and larger containers that are marketed to young people as single servings. Novelties such as test tube "shots," containers that look like dynamite, products with labels such as "Hot Sex," and beverages that change the color of the drinker's tongue promote hazardous drinking behaviour among young people.

Promotion - Young people are bombarded with $4 billion of alcohol marketing each year. Alcohol advertising is common on television and radio shows with a majority of underage viewers, on Internet sites attractive to young people, in magazines with large youth readerships, and on billboards and in retail outlets frequented by young people. The Federal Trade Commission reported that eight of the largest alcohol companies had made product placements in "PG" and "PG-13" movies with youth-oriented themes and large youth audiences and on eight of the 15 television shows most popular with teenagers. The alcohol industry regularly sponsors rock concerts, sporting events, and cultural and community celebrations with large youth audiences. Video games are another venue where the industry targets young people. Jack Daniels, for example, had a three-month product placement on schockwave.com's "real pool" video game, a popular youth web site; and Miller Beer uses video race car driving on its web site. College campuses are targets for aggressive, creative marketing campaigns by producers, distributors, and retailers. The alcohol industry's promotions directly contradict the social norm marketing messages. According to the advertisements, "everybody is doing it, and so should you." Testimonials by youth idols, including rap musicians, athletes, and movie stars, are common. The advertisements promise excitement, sex, glamour, rebellion, and sophistication, themes particularly important to young people. They often use child-friendly images such as cartoon characters, animals, and fast-paced animation. Public health and safety messages are notably absent, except for the federally-mandated warning labels on the bottle, printed in barely legible small type (a concession to the alcohol industry when Congress enacted the warning label legislation).

Place - Alcohol is one of the most readily available consumer products, often sold in retail venues frequented by young people. Many communities are saturated with alcohol outlets, particularly in college and low-income areas. College campuses may be surrounded by bars and liquor stores that are primary locations for entertainment and socializing and often offer drinking games and other marketing schemes that encourage heavy drinking. Alcohol sales are key to the success of convenience stores and gas stations, which are often located in residential areas, near schools, and in other child-friendly locations.

Price - Alcohol is cheap and becoming cheaper. The relative price of alcohol has been dropping steadily for the last five decades, in part due to the reduction of the real value of alcohol excise taxes, which have been eroded by inflation. Cheap beers are now roughly the same price as popular brands of soft drinks. Price promotions such as happy hours that promote hazardous drinking are common in college communities. Young people are particularly sensitive to alcohol prices: As relative prices decline, youth consumption increases. Researchers at the New York Bureau of Economic Research examined the potential impact on youth drinking if beer taxes had kept pace with inflation during the 1980s (adding approximately 14 cents to the cost of a bottle of beer). They estimated that high school seniors' heavy drinking rates (nine or more drinking episodes in the last month) would have decreased by 19 per cent, and hazardous drinking (five or more drinks in one setting during the previous two weeks) by 8.6 per cent. Taken together, these marketing strategies communicate a powerful message about alcohol's rôle in society. The marketing in college communities is particularly aggressive, promoting alcohol's glamour and attractiveness and making it readily available at low prices, variables that a recent study found to correlate directly with underage college binge drinking.

The Environmental Approach to Prevention: Implementing Alcohol Policies

Environmental prevention addresses these same variables, using policy interventions to create an alcohol environment that supports healthy, safe behaviour. Research over the last two decades (and described in more detail in several reports) demonstrates that these policy reforms work: They reduce the problems associated with youth drinking. For example:

• Increasing alcohol taxes and reducing discount drink specials substantially reduce heavy and hazardous drinking among college and high school students.

• Decreasing the number of alcohol outlets in a community is closely associated with reduction in rates of alcohol-related youth violence.

• Holding retailers liable for damage inflicted on others by intoxicated and underage patrons (asserting dram shop liability) promotes responsible server practices and reduces alcohol-related traffic crashes.

• Increasing the minimum legal drinking age to 21 substantially reduces youth alcohol-related motor vehicle crashes; and increasing enforcement of laws prohibiting sales to underage drinkers reduces youth access to alcohol.

• Reducing noncommercial forms of youth access to alcohol shows promise in reducing youth drinking problems.

• Reducing the amount of youth exposure to alcohol advertising and increasing the number of alcohol counter-ads have a positive impact on youth beliefs and intentions regarding alcohol use and may influence drinking decisions.

• Combining environmental strategies such as those listed above and implementing them in a comprehensive community programme results in substantial reductions in underage drinking and alcohol-related problem rates.

Various federal agencies and non-governmental organisations have recommended these and other alcohol policies, most of which receive strong support in national opinion surveys. Many are being implemented at the local level, responding to community concern and pressure for action. Local reforms include reduced numbers of alcohol billboards and other kinds of outdoor advertising, restrictions on the number and location of alcohol outlets, and reforms in alcohol server practices.

Environmental strategies complement, rather than replace, strategies targeting individual behaviour (such as social norms and other educational programmes). Individual-based programmes can have only limited impact if environmental forces undermine and contradict their messages and advice. Conversely, environmental strategies enhance individual-based strategies, by creating a social climate that reinforces the educational messages.

Alcohol Industry-sponsored Prevention Programmes in Perspective

Despite their promise, federal and state governments largely ignore environmental strategies as a means to address alcohol problems. This is largely due to the political influence of the alcohol industry, which opposes environmental strategies because of their potential adverse effect on industry profitability. The alcohol industry donated more than $11.7 million to the national Democratic and Republican parties and their candidates for federal offices in the 2000 election cycle, making it one of the most generous funders among major industries. Its political donations at the state level are equally impressive: in California alone, it donated more than $4 million to state political parties, candidates, and pro-industry voter initiative campaigns. The industry augments its political donations with the services of an army of well-connected, highly-paid lobbyists, who have ready access to the inner sanctums of state and federal power.

The industry's political muscle is effective. Advertising and tax reform have been largely thwarted by industry lobbying efforts in state and federal legislatures. In the late 1980s and early 1990s, the Center for Substance Abuse Prevention, a federal agency with the Department of Health and Human Services, funded community action programmes that included environmental strategies. The industry's aggressive attacks led CSAP to eliminate this portion of its programme. The industry is currently seeking to roll back past public health gains. For example, it is lobbying on behalf of HR 1305, which would substantially decrease beer taxes, and proposing a return to the 18-year minimum drinking age. At the state level, the industry has successfully rolled back many local initiatives by convincing state legislatures to enact preemptive legislation that nullifies local ordinances, thus hindering community efforts to create healthy alcohol environments.

The alcohol industry's support for social norms and other alcohol education programmes can only be understood within this broader social and political context: it views them as a substitute for, rather than a supplement to, environmental programmes. The industry's goal is to focus on individual behaviour, taking as a given the broader community context where its own marketing practices hold sway.

The industry's educational materials offer a consistent theme: Environmental strategies do not work and the individual drinker (or the underage individual with his or her parent) bears the sole responsibility for any problems that occur. The individuals the industry seeks to blame for problems with its products are also their best customers, and the industry's marketing budgets, which dwarf its expenditures on educational programmes, are tailored to reinforce and encourage heavy drinking behaviour. Perhaps most deceptive is the industry's claim that its educational and public awareness programmes targeting individual behaviour are effective in reducing alcohol problems and are largely responsible for gains that have been made in the last 15 years. Evaluation research provides no support for this view. In fact, one evaluation found that the beer industry's moderation and responsible drinking commercials send confusing messages and in many cases actually promote drinking. Lowered alcohol-related motor vehicle crash and under-age drinking rates are primarily the results of public policy reforms (such as the 21-year minimum drinking age laws) and changes in social norms, developments that the industry strongly opposed.

Within its own trade press, the industry makes the case explicitly: Its support for individual-level programmes is designed to blunt efforts to address environmental variables. In fact, the industry's initiatives are often crafted in direct response to alcohol policy campaigns that threaten its marketing interests. Its various anti-drunk driving educational campaigns are a counter to the efforts of Mothers Against Drunk Driving and other organisations to enact various alcohol policy measures to address the issue. When law enforcement began focusing on illegal alcohol sales to minors, the Century Council, a distilled spirits-funded organisation, developed the "Cops in Shops" programme to shift the responsibility from the retailer to the underage buyer. Industry-sponsored college campus programmes emerged after several alcohol-related school tragedies led to a reexamination of institutional alcohol environments and industry marketing strategies.

An additional weakness associated with industry-sponsored educational programmes is their lack of detail. Slogans such as "think when you drink" and "know when to say when," which are frequently targeted to underage youth, assume the recipient is drinking and provide no information regarding safe levels of drinking. Studies show that most people cannot accurately assess their own intoxication - in other words, do not think when they drink and do not know when to stop.

An industry priority embedded in these educational messages is an important marketing goal: to normalize drinking. According to Peter Cressy, the CEO of the Distilled Spirits Council of the United States: "DISCUS" is working to ensure cultural acceptance of alcohol beverages by 'normalising' them in the minds of consumers as a healthy part of a normal lifestyle." Cultural acceptance, he concludes, is the key to boosting industry sales. This priority reflects the industry's frustration that so many Americans drink so little or not at all, a major impediment to market growth. It also helps explain the industry's enthusiasm for social norms marketing: ignoring the environmental component, its messages blame deviant "irresponsible" drinkers for problems and normalise college drinking.

Does the industry's opposition to environmental strategies constitute a sufficient reason to refuse its funding and support for individual-based programmes? Why not collaborate on matters where there is agreement and agree to disagree where necessary? Organisations implementing social norm programmes, for example, may well support environmental strategies, such as reducing the number of bars and happy hour specials in the community. If industry support does not alter their position on these other policies, why not accept industry funding?

Before taking this step, prevention programmes need to consider what the industry gains from such collaboration. There are at least four benefits the industry seeks:

• Create positive public image - "innocence by association." Viewed by a majority as contributing to alcohol problems rather than helping to find solutions, the alcohol industry has historically had a negative public image, which detracts from its political agenda. The industry funds public awareness and educational programmes and builds collaboration with health and safety groups as a way to improve its public image, to claim the mantle of responsible corporate citizen. A group that agrees to collaborate with an industry member can anticipate that its name will appear in various industry publications distributed both to the public at large and to politicians and other decision makers.

• Defeat environmental policy proposals. As described above, the industry's educational initiatives are an integral part of its strategy to oppose measures that would impact its marketing agendas.

• Create dependence. The industry knows that funding affects priorities, even if no formal strings are attached. When a public health group agrees to accept industry funding, then its attention focuses on the programme at hand. Any pending work on alcohol-related issues and programmes slides down the agenda if the industry might object to it. The influence may be subtle. An organisation usually avoids offending a funder, so the impact may be in what is not done or said - through self-censorship and decisions regarding programme priorities.

• Influence programme content. The industry claims expertise in developing educational programmes for young people, parents, and the general public, and directly controls the content of most of its programmes, hiring those who develop them and reserving final approval. Individual companies, trade associations, and affiliated organisations all develop and distribute alcohol education materials. In some cases, the industry will fund programmes developed by others. In these cases of indirect influence, the programmes must meet industry criteria that disregard environmental and marketing issues and undermine important public health messages.

The industry garners these political and public relations benefits at a relatively modest cost. Although industry-wide data is not available, Anheuser-Busch, the largest alcohol company, estimates its expenditures on alcohol education and awareness efforts at $300 million between 1982 and 2000, or about $15 million per year. The company spent $232 million on measured media advertising in 1997, and probably an additional $464 million or more on unmeasured media. In other words, for every dollar it spends on alcohol education, the company spends $46 or more promoting beer.

The industry's efforts to control the content of alcohol educational materials raises a larger issue: What is the appropriate rôle for the alcohol industry in prevention? Its mission and expertise are to sell alcohol profitably, not to further public health and prevention education. Prudence dictates that the educational and marketing functions should be separated, with those in public health and education developing the programmes independently. The important rôle for the industry in prevention is to ensure that its marketing is not attractive to young people and does not promote problematic drinking practices.

Conclusion: Negotiating with the Alcohol Industry

Alcohol industry funding for educational and awareness programmes creates a thorny dilemma for many public health and safety groups. In many cases, nonprofit organisations need outside funding to maintain core programmes. An industry overture may trigger a heated internal debate that can weaken the organisation and divide key constituents, board members and staff. In these circumstances, an organisation should establish a deliberate plan of action designed to build internal strength, address the funding issues strategically, and enhance long-term prevention goals. Appendix A provides more detailed steps of such an action plan.

Our long-term goal, however, is to move beyond the issue of industry funding to address the industry's appropriate rôle in prevention. We want to shift from a reactive position, responding to industry overtures in the education and public awareness arenas, to a proactive stance, demanding that its marketing practices and their impact on community alcohol environments be an integral part of the discussion. To do this, an organisation needs to incorporate environmental strategies into its mission and programmes. This in turn provides the context for developing specific requests for industry action that will reduce environmental risk factors and change unhealthy social norms.

Experience shows that the industry will respond only when public health and safety groups organise a political base and build their political and media advocacy skills. Because the two sides have fundamentally different interests, the dialogue is in fact a negotiation, and the outcome rests in large measure on the relative political power each brings to the table. In most cases, agreements should lead to clear, enforceable guidelines, typically through ordinances, regulations, or statutes.

Marketing reforms are usually best started and built at the local level, negotiating with retailers. Local policy makers are more accessible and responsive to constituents, and local retailers are likely to be sensitive to community concerns. Reform at state and federal levels is more difficult, since alcohol producers bring enormous political power to these arenas, policy makers are more dependent on industry donations, and constituents have a harder time making their voices heard.

Clearly, the alcohol industry plays a critical rôle in the alcohol policy field. The questions are: What is that rôle? And who defines it? We must ensure the influence of the industry's marketing practices on community alcohol environments be part of any dialogue about the industry's corporate responsibilities. Industry offers to fund and support individual-based awareness and education programmes should not distract us from this fundamental issue.